Healthcare Provider Details

I. General information

NPI: 1730923731
Provider Name (Legal Business Name): CHRISTIAN CHAPMAN KENT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N MARINE DR
CHICAGO IL
60640-5759
US

IV. Provider business mailing address

555 W KINZIE ST
CHICAGO IL
60654-5727
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8700
  • Fax:
Mailing address:
  • Phone: 712-389-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135.001228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: